Awake Craniotomy Language Mapping in Children With Drug-Resistant Epilepsy due to Focal Cortical Dysplasia

BACKGROUND

Language mapping during awake craniotomy can allow for precise resection of epileptogenic lesions, while reducing the risk of damage to eloquent cortex. There are few reports in the literature of language mapping during awake craniotomy in children with epilepsy. Some centers may avoid awake craniotomy in the pediatric age group due to concerns that children are unable to cooperate with such procedures.

METHODS

We reviewed pediatric patients from our center with drug-resistant focal epilepsy who underwent language mapping during awake craniotomy and subsequent resection of the epileptogenic lesion.

RESULTS

Two patients were identified, both female, aged 17 years and 11 years at the time of surgery. Both patients had frequent and disabling focal seizures despite trials of multiple antiseizure medications. Both patients had resection of their epileptogenic lesions with the aid of intraoperative language mapping; in both cases pathology was consistent with focal cortical dysplasia. Both patients had transient language difficulties in the immediate postoperative period but no deficits at six-month follow-up. Both patients are now seizure-free.

CONCLUSIONS

Awake craniotomy should be considered in pediatric patients with drug-resistant epilepsy in whom the suspected epileptogenic lesion is in close proximity to cortical language areas.

Randomized placebo-controlled crossover trial of memantine in children with epileptic encephalopathy

Memantine is an N-methyl-D-aspartate receptor antagonist, approved for dementia treatment. There is limited evidence of memantine showing benefit for paediatric neurodevelopmental phenotypes, but no randomized placebo-controlled trials in children with developmental and epileptic encephalopathy. In this randomized double-blind placebo-controlled crossover trial (Trial registration: https://clinicaltrials.gov/ct2/show/NCT03779672), patients with developmental and epileptic encephalopathy received memantine and placebo, each for a 6-week period separated by a 2-week washout phase. Electroencephalography, seizure diary, patient caregivers' global impression, serum inflammatory markers and neuropsychological evaluation were performed at baseline and after each treatment phase. The primary outcome measure was classification as a 'responder', defined as ≥2 of: >50% seizure frequency reduction, electroencephalography improvement, caregiver clinical impression improvement or clear neuropsychological testing improvement. Thirty-one patients (13 females) enrolled. Two patients withdrew prior to initiating medication and two (twins) had to be removed from analysis. Of the remaining 27 patients, nine (33%) were classified as responders to memantine versus two (7%) in the placebo group (P < 0.02). Electroencephalography improvement was seen in eight patients on memantine compared to two on placebo (P < 0.04). Seizure improvement was observed in eight patients on memantine and two on placebo (P < 0.04). Caregivers reported overall clinical improvement in 10 patients on memantine compared to seven on placebo (not significant). Statistical analysis of neuropsychological evaluation suggested improvements in symptoms of attention-deficit hyperactivity disorder and autism. Memantine is a safe and effective treatment for children with developmental and epileptic encephalopathy, having the potential to improve both seizure control and cognitive function.

Diagnostic utility of specific abnormal EEG patterns in children for determining epilepsy phenotype and presence of structural brain abnormalities

Objective

Estimate sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EEG findings: centrotemporal spikes, photoparoxysmal response, asymmetric photic driving, and asymmetric sleep spindles, for epilepsy phenotype and presence of structural brain abnormalities.

Methods

In this case-control study we reviewed children referred for EEG over a 4-year period, with at least one of centrotemporal spikes, photoparoxysmal response, asymmetric photic driving, or asymmetric sleep spindles. This cohort was analyzed in combination with a research database of pediatric patients with seizures.

Results

Centrotemporal spikes had 100% sensitivity for childhood epilepsy with centrotemporal spikes or atypical childhood epilepsy with centrotemporal spikes, but lower specificity (70%) and PPV (58%). Photoparoxysmal response had high specificity (92%) and NPV (92%) for genetic generalized epilepsy. Asymmetric photic driving had low sensitivity for structural brain abnormalities (17%), with specificity 80%. In contrast, asymmetric sleep spindles had much higher sensitivity and specificity, 44% and 97%, respectively.

Conclusions

Although centrotemporal spikes are classically associated with childhood epilepsy with centrotemporal spikes, these discharges are seen in other conditions. Photoparoxysmal response is highly indicative of a genetic generalized epilepsy, though may be seen in other epilepsy phenotypes. Relative attenuation of sleep spindles is a more reliable indicator of structural brain malformation than asymmetric photic driving.

Significance

The quantitative diagnostic utility of EEG findings should be considered when incorporating these results into clinical decision-making.

Case Report: Aperiodic Fluctuations of Neural Activity in the Ictal MEG of a Child With Drug-Resistant Fronto-Temporal Epilepsy

Successful surgical treatment of patients with focal drug-resistant epilepsy remains challenging, especially in cases for which it is difficult to define the area of cortex from which seizures originate, the seizure onset zone (SOZ). Various diagnostic methods are needed to select surgical candidates and determine the extent of resection. Interictal magnetoencephalography (MEG) with source imaging has proven to be useful for presurgical evaluation, but the use of ictal MEG data remains limited. The purpose of the present study was to determine whether pre-ictal variations of spectral properties of neural activity from ictal MEG recordings are predictive of SOZ location.We performed a 4 h overnight MEG recording in an 8-year-old child with drug-resistant focal epilepsy of suspected right fronto-temporal origin and captured one ~45-s seizure. The patient underwent a right temporal resection from the anterior temporal neocortex and amygdala to the mid-posterior temporal neocortex, sparing the hippocampus proper. She remains seizure-free 21 months postoperatively. The histopathological assessment confirmed frank focal cortical dysplasia (FCD) type IIa in the MEG-defined SOZ, which was based on source imaging of averaged ictal spikes at seizure onset. We investigated temporal changes (inter-ictal, pre-ictal, and ictal periods) together with spatial differences (SOZ vs. control regions) in spectral parameters of background brain activity, namely the aperiodic broadband offset and slope, and assessed how they confounded the interpretation of apparent variations of signal power in typical electrophysiological bands. Our data show that the SOZ was associated with a higher aperiodic offset and exponent during the seizure compared to control regions. Both parameters increased in all regions from 2 min before the seizure onwards. Regions anatomically closer to the SOZ also expressed higher values compared to contralateral regions, potentially indicating ictal spread. We also show that narrow-band power changes were caused by these fluctuations in the aperiodic component of ongoing brain activity. Our results indicate that the broadband aperiodic component of ongoing brain activity cannot be reduced to background noise of no physiological interest, and rather may be indicative of the neuropathophysiology of the SOZ. We believe these findings will inspire future studies of ictal MEG cases and confirm their significance.

Prosopagnosia seizure semiology in a 10-year-old boy: a functional neuroimaging study

We illustrate a case of post-traumatic recurrent transient prosopagnosia in a paediatric patient with a right posterior inferior temporal gyrus haemorrhage seen on imaging and interictal electroencephalogram abnormalities in the right posterior quadrant. Face recognition area mapping with magnetoencephalography (MEG) and functional MRI (fMRI) was performed to clarify the relationship between the lesion and his prosopagnosia, which showed activation of the right fusiform gyrus that colocalised with the lesion. Lesions adjacent to the right fusiform gyrus can result in seizures presenting as transient prosopagnosia. MEG and fMRI can help to attribute this unique semiology to the lesion.

Copy number variation in genetic epilepsy with febrile seizures plus

AIM

Genetic epilepsy with febrile seizures plus (GEFS+) is a familial epilepsy syndrome in which affected individuals may have a variety of epilepsy phenotypes, the most common being febrile seizures (FS) and febrile seizures plus (FS+). We investigated the possible contribution of copy number variation to GEFS+.

METHOD

We searched our epilepsy research database for patients in GEFS + families who underwent chromosomal microarray analysis. We reviewed the clinical features and results of genetic testing in these families.

RESULTS

Of twelve families with available microarray data, four had at least one copy number variant (CNV) identified. In Family 1, the proband had a maternally-inherited 15q11.2 deletion. In Family 5, four different CNVs were identified, variably present in the affected individuals; this included a 19p13.3 deletion affecting CACNA1A. Finally, in both Families 9 and 10, the proband had Dravet syndrome with pathogenic SCN1A variant, as well as a CNV (10q11.22 duplication in Family 9 and 22q11.2 deletion in Family 10).

INTERPRETATION

The significance of these specific variants is difficult to precisely determine; however, there appeared to be an overrepresentation of CNVs in this small cohort. These findings suggest chromosomal microarray analysis could have clinical utility as part of the workup in GEFS + families.

X-Linked Familial Focal Epilepsy Associated With Xp22.31 Deletion

BACKGROUND

The genetic basis for familial focal epilepsy is poorly understood, with most of the known genetic causes occurring via autosomal dominant inheritance. X-linked familial focal epilepsy has not been previously reported.

METHODS

We reviewed our research database for cases of X-linked focal epilepsy.

RESULTS

We identified three boys with X-linked ichthyosis and focal epilepsy, including two maternal cousins. Age of seizure onset ranged from seven to 10 years, and all three patients had seizures that were relatively easily controlled. The epilepsy phenotype in all boys was consistent with self-limited focal epilepsy of childhood, most closely resembling childhood epilepsy with centrotemporal spikes. Brain magnetic resonance imaging was normal in two of the boys, with a third found to have a suspected focal cortical dysplasia. All three boys carried maternally inherited hemizygous Xp22.31 deletions (estimated size 0.9 to 1.66 Mb), affecting four to six genes. Of the affected genes, only STS has clear clinical relevance; deletions, and pathogenic variants in STS cause X-linked ichthyosis, although all patients described had only minor skin findings.

CONCLUSIONS

The findings in these patients illustrate that X-linked familial focal epilepsy can occur, although it is a rare entity. Although STS pathogenic variants are likely better categorized as an epilepsy risk factor, variants in this gene may partially explain the male predominance observed in specific epilepsy phenotypes, namely childhood epilepsy with centrotemporal spikes.

KCNT1-related epilepsy: An international multicenter cohort of 27 pediatric cases

OBJECTIVE

Through international collaboration, we evaluated the phenotypic aspects of a multiethnic cohort of KCNT1-related epilepsy and explored genotype-phenotype correlations associated with frequently encountered variants.

METHODS

A cross-sectional analysis of children harboring pathogenic or likely pathogenic KCNT1 variants was completed. Children with one of the two more common recurrent KCNT1 variants were compared with the rest of the cohort for the presence of particular characteristics.

RESULTS

Twenty-seven children (15 males, mean age = 40.8 months) were included. Seizure onset ranged from 1 day to 6 months, and half (48.1%) exhibited developmental plateauing upon onset. Two-thirds had epilepsy of infancy with migrating focal seizures (EIMFS), and focal tonic seizures were common (48.1%). The most frequent recurrent KCNT1 variants were c.2800G>A; p.Ala934Thr (n = 5) and c.862G>A; p.Gly288Ser (n = 4). De novo variants were found in 96% of tested parents (23/24). Sixty percent had abnormal magnetic resonance imaging (MRI) findings. Delayed myelination, thin corpus callosum, and brain atrophy were the most common. One child had gray-white matter interface indistinctness, suggesting a malformation of cortical development. Several antiepileptic drugs (mean = 7.4/patient) were tried, with no consistent response to any one agent. Eleven tried quinidine; 45% had marked (>50% seizure reduction) or some improvement (25%-50% seizure reduction). Seven used cannabidiol; 71% experienced marked or some improvement. Fourteen tried diet therapies; 57% had marked or some improvement. When comparing the recurrent variants to the rest of the cohort with respect to developmental trajectory, presence of EIMFS, >500 seizures/mo, abnormal MRI, and treatment response, there were no statistically significant differences. Four patients died (15%), none of sudden unexpected death in epilepsy.

SIGNIFICANCE

Our cohort reinforces common aspects of this highly pleiotropic entity. EIMFS manifesting with refractory tonic seizures was the most common. Cannabidiol, diet therapy, and quinidine seem to offer the best chances of seizure reduction, although evidence-based practice is still unavailable.

Fragile Females: Case Series of Epilepsy in Girls With FMR1 Disruption

Girls with pathogenic variants in FMR1, the gene responsible for Fragile X syndrome, have received relatively little attention in the literature. The reports of girls with trinucleotide expansions or deletions affecting FMR1 describe variable phenotypes; having normal intelligence and no severe neurologic sequelae is not uncommon. We reviewed epilepsy genetics research databases for girls with FMR1 pathogenic variants and seizures to characterize the spectrum of epilepsy phenotypes. We identified 4 patients, 3 of whom had drug-resistant focal epilepsy. Two had severe developmental and epileptic encephalopathy with late-onset epileptic spasms. Our findings demonstrate that FMR1 loss-of-function variants can result in severe neurologic phenotypes in girls. Similar cases may be missed because clinicians may not always perform Fragile X testing in girls, particularly those with severe neurodevelopmental impairment or late-onset spasms.

The Diagnostic Accuracy of Prolonged Ambulatory Versus Routine EEG

Prolonged ambulatory electroencephalography (paEEG) is increasingly used in clinical practice but its diagnostic accuracy relative to that of routine EEG (rEEG) remains uncertain. We examined a consecutive sample of 72 individuals who had undergone 32-channel paEEG immediately after an rEEG, creating perfectly matched EEG samples. Each recording was prospectively assessed for epileptiform discharges (ED) and nonepileptiform abnormalities. The median paEEG duration was 22.5 hours (interquartile range: 22.0-23.0). The sensitivity of paEEG was 2.23 times greater than that of rEEG [sensitivity ratio: 2.23 (95% CI=1.49-3.34)] if a positive test was limited to the presence of epileptiform discharges. This benefit of paEEG versus rEEG was no longer evident if the definition of a positive test included nonepileptiform abnormalities (sensitivity ratio 1.26; 95% CI=1.02-1.55). The specificity of the 2 tests was not evidently different (specificity ratio 0.67; 95% CI=0.17-2.67). Twenty-six percent of paEEG recorded epileptic seizures while none of the rEEG did (absolute difference 26.0% (95% CI=11.8-40.2). Our findings quantify the benefit of 32-channel paEEG, relative to rEEG, and support its role in the diagnosis and characterization of epilepsy.

Sleep in children with cerebral palsy: a review

Children with neurodevelopmental disabilities, such as cerebral palsy, are considered to be a population at risk for the occurrence of sleep problems. Moreover, recent studies on children with cerebral palsy seem to indicate that this population is at higher risk for sleep disorders. The importance of the recognition and treatment of sleep problems in children with cerebral palsy cannot be overemphasized. It is well known that the consequences of sleep disorders in children are broad and affect both the child and family. This review article explores the types and possible risk factors associated with the development of sleep problems in children with cerebral palsy and the impact of this disorder on the child and family. In addition, a brief summary of current diagnostic and treatment modalities is provided. Finally, the characteristics, diagnostic techniques, and management of sleep-related breathing disorders in children with cerebral palsy are discussed.

Determinants of ambulation in children with spastic quadriplegic cerebral palsy: a population-based study

The objective of this study was to identify factors that predict ambulation in spastic quadriplegic cerebral palsy. A 4-year registry-based birth cohort was searched for patients with a diagnosis of spastic quadriplegic cerebral palsy. All patients were then divided in 2 groups: (a) Gross Motor Function Classification System level < or = III (ambulant group) and (b) Gross Motor Function Classification System level > or = IV (nonambulant group). Clinical features were then compared between the 2 groups. A total of 85 children with a diagnosis of spastic quadriplegic cerebral palsy were identified. Of these, 65 and 20 were classified in the ''nonambulant'' and ''ambulant'' groups, respectively. The presence of seizures in the first 24 or 72 hours of life and the administration of antibiotics during pregnancy/delivery were all associated with an eventual inability to achieve ambulation. A gestational age < or = 27 weeks, birth weight <1000 g, Caucasian mother, and the presence of hyperbilirubinemia were significantly linked with independent ambulation.

Features of a subset of children with complex partial epilepsy requiring combination therapy for effective seizure control

To identify children with complex partial seizures with increased risk for suboptimal seizure control with 1 medication, a computerized database containing all patients seen in the context of a single pediatric neurology practice was reviewed for patients with complex partial seizures. Participants included in analysis were then divided into groups; a group in whom seizure control was attained with a single medication (group 1) and a group for whom 2 or more medications were required for seizure control (group 2). Status epilepticus, developmental disabilities, and the presence of coexisting other seizures/types were also significantly different, with a higher predominance in group 2 children. Patients with status epilepticus, coexistent seizure types, and developmental disabilities should be identified and more carefully followed, with a lower threshold for starting these children on a combination of antiepileptic drugs adhered to.

A profile of adolescent-onset epilepsy

To describe the profile of children with adolescent-onset epilepsy and to determine factors predictive of outcome. A database was searched for all patients with a first seizure between the age of 12 and 16 years. Sixty-five adolescents met inclusion criteria. Ten patients needed at least two medications to control seizures, 36 remained on medication at their last visit and 12 patients had at least 1 seizure in the year preceding. A diagnosis of juvenile myoclonic epilepsy, the presence of coexisting seizures, coexisting myoclonic seizures, age < or =14.5 years at initial diagnosis, and the presence of compliance issues were significantly associated with the need for medication at last visit. Female gender and the presence of compliance issues were associated with the occurrence of at least 1 seizure in the year preceding last visit. A good outcome for adolescent-onset epilepsy can generally be expected in the short term.

Compliance with Fluoride Supplements Provided by a Dental Hygienist in Homes of Low-Income Parents of Preschool Children in Quebec

OBJECTIVE

This study aimed to assess the compliance with fluoride supplements provided at home by a dental hygienist to mothers of at-risk preschool children.

METHODS

Participants were recruited during pregnancy of low-income women. On the first visit, the mothers of 60 infants aged 6 to 9 months were handed free fluoride supplements. A questionnaire was administered at that time and after 6 and 12 months to assess compliance during the preceding week.

RESULTS

At the beginning of the study, none of the mothers reported having given fluoride supplements, in comparison with 73 percent of mothers of 44 infants who received all three visits at the end of follow-up; 48 percent reported fluoride supplement use on a daily basis.

CONCLUSIONS

Removal of financial and physical barriers and personal professional involvement are good strategies to achieve compliance with fluoride supplements. Further assessment regarding the possible application of this intervention to other professional or cultural contexts is warranted.